Book Review: At What Cost: Modern Capitalism and the Future of Health

Freudenberg published “At What Cost” in 2021, documenting the exponential rise of corporate control of the health economy, and cataloguing the corresponding expansion of profits. These developments have been turbo charged by corporate and government responses to the Covid pandemic.

As you read this eclectic work it is hard not to be overwhelmed by the consequences for public health as corporations exert influence over the US political and regulatory environment. Freudenberg employs a broad, multi-sector analysis exposing the cumulative effects from deregulation, privatisation, and corresponding governance changes to: education; labour rights and working conditions; food insecurity; public transport; health systems and social justice/welfare policies – with corresponding implications for the global environment and population-wide mental health and wellbeing.

These “Pillars of Health” are specifically interrogated, meticulously documented, and the outcomes alarming. Readers will learn much that will shock, especially the descriptions of how some corporate behemoths impose neo-feudal working conditions, externalising their costs to workers and governments. These draconian, contractual, and penalty systems employed by Walmart, Tech giants, and others actively block any labour union activity. Freudenberg records there are 53 million low wage/precarious workers in the US.

Additionally, Freudenberg reveals that 70 percent of research undertaken in the US is funded by corporations, thus raising concerns of possible consequences for innovation. Corporate investments in the promotion of ultra-processed foods (HPF) and new marketing of “toddler food,” as well as extensive investment in childcare and education services have led to their privatisation. In some cases, such practices included the outsourcing of research and development, such as, in once case, the outsourcing of 60 percent of US testing to a UK company. The activities of US philanthropic foundations are also scrutinised given their influence over cultural, religious, and market focused public health policies. And a critical analysis of the tarnished US health system is assessed against ongoing failures in the treatments of cancer.

Working through all these sectors, Freudenberg has systematically provided an evidential base revealing the intersection between public health objectives and neo-liberal objectives and outcomes. This book therefore poses a challenge to policy makers to understand the complexity and consequences resulting from economy-wide applications of the neo-liberal deregulatory policies now embedded in public policy, and reinforced over the last fifty years. Any perceived negative effects are generally described by economists as simply unintended consequences.

If, however, as Freudenberg and others claim, these negative “unintended consequences” are instead embedded and directly resulting from current social/economic frameworks driving 21st century modern capital, then a different frame of reference is required. The sustainability of current levels of public and mental health costs are already problematic for democratically responsive governments, as are the financial/political costs of providing subsistence financial and in-kind health support to millions of “working poor.” Neo-liberalism and its ideological underpinnings are self-perpetuating, not self-correcting.

Freudenberg’s analysis is complex and excoriating. His research records the expansion of the role and power of corporations, contrasting with the dwindling tax base and shrinking role of government. Consequentially, this hollowing out of public services, and privatisation affecting all manner of national assets and key public infrastructure, has contributed to undermining public health outcomes and social development. In addition, the political shift from protecting consumers to more actively supporting corporations’ interests is likely to skew health related research. Meanwhile, expanding intellectual property rights and monopoly protection, and implementing regulation designed by industry insiders, undermines democracy. Importantly, this downsizing and recalibration of the role of government also marginalises and delegitimises the political underpinnings of the Post WWII social welfare paradigm.

Such critics are not new, but Freudenberg’s specific analysis adds substantially to the broader political-economy critique of neo-liberalism. But it should be noted that his focus is on the fault lines around what he terms “modern capitalism” and is not a grand Marxian critique of capitalism. Of significance, however, is that Freudenberg has cast aside the McCarthyite legacy of fear that has stymied critiques of “capitalism.” “In At What Cost, I choose to use the word capitalism, focusing on the variant that has emerged in the last few decades, what I call modern capitalism or 21^st century capitalism,” he writes.

Freudenberg is seeking to reconstitute an economic/social/policy environment for a modern public health agenda, building upon earlier progress. This means learning, for example, from the Keynesian Welfare Economic and social justice models that were inclusive of labour, human rights, educational advancement, and the vibrant social rights movements of the 1960s. These models and policies led to the unprecedented growth of the middleclass and facilitated governance and policy agendas that saw sustainable public health policies transform the health, education, and welfare of so many, both in the US and elsewhere.

By contrast, it was the Reagan/Thatcher neo-liberal small government agenda with its emphasis on privatisation of national resources, of public services, and the unprecedented power of corporations, that is critiqued. A shocking take-away here is that every major industrial sector in the global economy is controlled by no more than five transnational corporations. The scope and critique of the effects on public health expose the underbelly of modern capitalism. And his key question is challenging for all involved in public health. “Can a twenty-first century public health movement advance a comprehensive agenda for the incremental and transformative changes that could detoxify those elements of modern capitalism that endanger health such as corporate-managed globalizations, financialization, deregulation, and business control of science and technology?”

This book is an extremely valuable text with countless references supporting analysis of the economic and political factors that impact both the physical and mental health of populations. This eclectic approach analyses the health effects on the working poor and also more broadly as the incidence of obesity, diabetes, and mental health costs expand. It challenges public health practitioners and policy makers to understand the public health consequences if the political and governance underpinnings of this “modern capitalism model” are not adapted to comply with a different set of sustainable, people-centred public health priorities. Chapters 8-9 offer a range of alternative policies and actions to achieve such outcomes.

Freudenberg’s analysis and his policy prescriptions also support the work needed to effectively action the World Health Organization’s (WHO) One Heath Agenda. Therefore, it should be noted that Freudenberg’s “Pillars of Health” research links into the UN’s Social Determinants of Health strategy and compliments WHO’s One Health Agenda, including addressing the growth of antimicrobial resistance.

Also, he recognises it can be difficult for those responsible for developing public health policies to actively input or to understand the possible consequences for health policy. For example, related to agendas such as WTO/FTA negotiations are significant health costs and access to pharmaceuticals. Some unexpected barriers that can legally and financially impact on government’s capacity to regulate health, the use of pesticides or to act on climate change health issues can be stymied through the use of  Investor State Dispute Agreements (ISDS). All can limit government’s capacity to alter domestic policy parameters to safeguard public health.

Several of these legal, financial, and access implications flowing from WTO/FTAs and related globalisation strategies embedded in modern capitalism have been explored and explained in the book. This should help make more transparent the global scale of modern capitalism for health practitioners, policy makers, politicians, and the media.

Freudenberg presents the analytical and intellectual tools to make the changes so desperately needed for those who wish to recreate a sustainable, functioning public health paradigm. This book is a substantive contribution to understanding the complex intellectual parameters of Public Health.

This is a review of Nicholas Freudenberg’s At What Cost: Modern Capitalism and the Future of Health (Oxford University Press, 2021) ISBN: 9780190078621

Anna George is a former Australian ambassador and multilateral negotiator.  Currently an adjunct professor at the College of Arts, Business, Law and Social Sciences at Murdoch University. Her interests include the trade and security aspects linked to the spread of antimicrobial resistance through the international food chain and the role of FTAs and WTO obligations influencing government’s decision making.

This article is published under a Creative Commons License and may be republished with attribution.